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NTSB: "Inadequate risk assessment" led to fatal 2018 train accident near Cayce

Two Amtrak crew members died in the accident and 74 others were injured in collision with CSX freight train

COLUMBIA, S.C. — The National Transportation Safety Board met Tuesday morning in Washington, DC, to discuss the investigation and possible cause of the 2018 collision between an Amtrak passenger train and a stopped CSX freight train near Cayce, SC.

The official report states that probable cause for the accident was with CSX Transportation's failure to properly assess and mitigate the risk of conducting switching operations during a signal suspension, coupled with a CSX conductor’s error.

Investigators concluded that at the time of the incident:

  • there was a work order for a signal upgrade on the tracks, affecting 23 miles of track under suspension. The work was scheduled to go from 7 am to 7 pm on Saturday and Sunday.
  • CSX chose not to stop train traffic during that 12-hour window and instead ran three trains through the area, taking up about six hours of signal suspension. The investigators believe that the work could have been completed within the first 12-hour window if the company had not chosen to continue train operations.
  • the CSX conductor failed to realign a switch, an error of omission. Omission errors are more likely to occur when steps are repeated, located near the end of a task sequence, and require alternative operating procedures. These factors were comparable to realigning the switch. The locomotive crew made approximately 124 movements during the shift which required the conductor to repeatedly operate switches. The accident occurred at the end of the shift and it was dark and no lights at the switch.
  • the misaligned switch diverted the southbound Amtrak Train 91 from the main track into the storage track, causing the head-on collision with the stationary CSX freight train. The Amtrak train was going about 50 miles an hour at the time of impact and traveled about 660 feet past the switch after impact.

As a result of the collision, the two Amtrak crew members on the lead locomotive died. 92 persons, passengers and crew, were transported to local hospitals. 74 of the 92 were confirmed injured, nine were coded as serious.

Investigators cited other accidents caused by misaligned switches, including the ruptured chlorine tank car incident in Graniteville, in 2005, that released a toxic chlorine cloud that killed nine people, caused 500 to be treated at local hospitals, and an evacuation of 5,400 residents.

RELATED: Graniteville residents remember 2005 crash

The investigation found the CSX crew had responsibility to ensure that the main track switch was properly aligned prior to releasing the track authority. The CSX crew was also required to maintain a switch position awareness form. The information on that is required to be reported to the train dispatcher and the form includes the name of the employee who operated the switch, and the location and time the switches were operated. 

NTSB investigators did not find the completed form. In NTSB interviews, the crew said that they did not accurately complete the form.

The NTSB also looked at Amtrak and that company's processes. 

RELATED: Railroads have improved safety since fatal SC collision, Amtrak and CSX officials say

Reliance on host railroads (deemed off-property rail) is a central feature of Amtrak's business model. Ninety-seven percent of the routes that Amtrak owns rely on off-property rail and are subject to all the operating safety rules, orders, procedures and standards of the host company that actually owns the rail line. 

The NTSB found that "at the time of the accident, Amtrak did not have a strategy for managing safety off property beyond the selection of operating rules.

"They followed each host railroad without conducting risk assessments. Crews and passengers were exposed to risk depending on location. 

"After the accident Amtrak, senior officials question the policy without first conducting risk assessments, recognized that Amtrak would not have routed the train on their property this way. However, this practice was followed on CSX track and, as per Amtrak policy at the time, they followed CSX rules. 

"Amtrak accepted a higher level of risk off-property than it would have accepted on its own property."

The NTSB said that Amtrak's failure to do a risk assessment on using tracks that are operating under signal suspension was a contributing factor to the accident. 

The official report states: "Although Amtrak meets and exceeds FRA’s safety standards to ensure safe operations of its own railroads, Amtrak trains relied only on the minimum federal safety standards when operating on host railroads. Amtrak needs to implement a safety management system on all operations whether operating on their own tracks or on a host railroad."

RELATED: New video surfaces of Amtrak train crash in Lexington County

In the question and answer period following the investigative presentation, Robert Sumwalt, chairman of the NTSB, summarized the findings in this way:

“… with every switch movement, like I said, there is the hazard of not repositioning it. And yet they put this crew out there that night in a situation where they were constantly moving switches, including mainline switches, including the storage north signal or north switch which is the one that ultimately did not get realigned.

“So, CSX did not take measures to mitigate, proper measures to mitigate the risk associated with this.

“They did not have to choose to conduct a switching operation during the signal suspension. As Reuben (Payan, NTBS investigator) said, they could have chosen not to even operate trains through there. … They could have -- they -- so there were a lot of things they could have done other than relying on these weak administrative controls, because invariably humans will commit errors.

“We have to have enough redundancy in the system so that when that error is committed that error will be trapped before bad things happen. And CSX failed to do that.”

As a result of the investigation, the NTSB issued three new safety recommendations, two of which were issued to the CSX Transportation. These recommendations address safety issues including actions and responsibilities of the train crew in handling switches. One recommendation issued to all host railroads is to work in partnership with Amtrak to implement a Safety Management System to assess and mitigate risks for operation on host railroads.

In addition, the NTSB reiterated four recommendations to the FRA, and one issued to Amtrak. Two recommendations to the FRA have been reclassified including one urgent safety recommendation calling on the FRA to provide instructions for railroads to follow when signal suspensions are in effect, and a switch has been reported relined for a main track.

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